CHOLELITHIASIS [Autosaved]
-
Upload
rnzznier4725 -
Category
Documents
-
view
228 -
download
0
Transcript of CHOLELITHIASIS [Autosaved]
-
7/31/2019 CHOLELITHIASIS [Autosaved]
1/36
(GALL STONES)
CHOLELITHIASIS
-
7/31/2019 CHOLELITHIASIS [Autosaved]
2/36
INTRODUCTION
-
7/31/2019 CHOLELITHIASIS [Autosaved]
3/36
Cholelithiasis (Gallstones)
It is the presence of stone in the gallbladder.
Gallstones are crystalline structures formed by concretion oraccretion of normal or abnormal bile constituents.
Ultrasonography and Xray detect gallstones.
Cholecystolithiasis It is the presence of one or more gallstones in the
gallbladder. Diagnostic Sonography (Ultrasonography) and Percutaneous
Transhepatic Cholangiography technique used to visualizethe biliary tract.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
4/36
PATIENTS PROFILE
Name: Mrs. ACAge: 61 y/oDate of Birth: September 01, 1949Status: MarriedNationality: FilipinoReligion: Catholic
Home address: 7A, Don Julio Gregorio, Bagbag, Novaliches, Q.C.Occupation: NONEChief Complaint: Right Upper Quadrant PainAdmitting diagnosis: CholecystolithiasisAdmitted by at: 7:00 pm
On: May 06, 2011Operated: May 17, 2011
-
7/31/2019 CHOLELITHIASIS [Autosaved]
5/36
THEORETICAL FRAMEWORK
We chose Orems theory which includes three related concepts: self-care, self-care deficit, and nursing systems. Self-care theory has self-care, self-care requisites, and therapeutic self-care demand. Self-care refers to activitiesan individual performs independently throughout life to promote andmaintain personal well-being. Self-care requisites, also called self-care needs,are measures or actions taken to provide self-care. There are three categories
of self-care requisites:Universal requisites, include maintaining intake and elimination of
air, water, and food.
Developmental requisites are associated with conditions or events,such as adjusting to a change in body image.
Health Deviation requisites result from illness, injury, or disease or itstreatment. They include actions such as carrying out prescribed therapies, andlearning to live with the effects of illness or treatment.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
6/36
PERSONAL
DATA
-
7/31/2019 CHOLELITHIASIS [Autosaved]
7/36
Patients Name: ACAge: 61 years oldGender: Female
History of Present Illness:1 year PTC - patient had pain onRUQ area. No other symptomsnoted. Consult due Ultrasound:
Fatty liver, gallbladder not dilatedwith multiple gallbladder stones,length 1.3 cm.
1month PTC- Patients UltrasoundResult: (+) Fatty liver still withmultiple gallbladder stones, length1.2 cm.
Family Medical History:
(+) HPN & DMmother
(-) Cancer(-) Asthma
P/S History:
(-) smoker(-) alcoholic beverage drink
Vital Signs:Temperature- 36.9Pulse Rate- 74 bpmRespiration Rate- 19cpmBlood pressure- 130/90 mm/Hg
-
7/31/2019 CHOLELITHIASIS [Autosaved]
8/36
GORDONSFUNTIONAL HEALTHPATTERN
-
7/31/2019 CHOLELITHIASIS [Autosaved]
9/36
Gordons functional
health patterns
Before During Interpretation Analysis
HEALTH PERCEPTION The patient
sees health as a
very important
aspect in life.
She gives
importance to it.
Coordinates
in the post-
operative
nursing care.
The patient
responds
very well in
the
treatment
given to her.
Cooperation helps
the patient in
recovering to
achieve optimum
healing.
NUTRITIONAL-
METABOLIC
Eats 3x a day,
fond eating
chicharon.
Eats anything
prepared
especially
bagoong,
alamang, seedy
and fatty foods.
Drinks 2-3L/day
On DAT diet
Taste foods
as tasteless
Adviced to
eat low salt-
low fat diet.
Drinks 1-
2L/day
Food Restriction
insufficient fluid
intake
She is restricted to
foods that can
worsen her
condition. She is
given a diet to
promote early
recovery.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
10/36
Elimination Moves bowel
once a day.
In the morning,
usually soft
brown color, had
clay colored stool
1 week before the
admission.
Voids 5-6 times a
day, dark yellow
in color
Hx of UTI.
Moved bowel once,
soft light yellow
stool.
Voids 3-4 times a
day light yellow in
color.
Color of Stool
changed from
clay to light
yellow.
Urine changed
from dark yellow
to light yellow.
Clay-colored stool
and dark yellow
colored urine is a
result from
obstruction of bile.
ACTIVITY-
EXERCISE
Does household
chores, takes careof grandchild and
jogs atleast 1 hour
in the morning
Not doing household
chores. Needs assistance
during ambulatory
Walks as exercise
Normal Normal
-
7/31/2019 CHOLELITHIASIS [Autosaved]
11/36
SLEEP-REST Sleeps 9-10 hours
a day
Experiences
waking up at
midnight, voidsthen return sleep
again.
Sleeps usually 7pm
until 4am.
Does not taking a
nap.
Sleeps longer
Can sleep
anytime
Have naps
duringafternoon
But
experienced
difficulty in
falling asleep
because of
noisy and hot
environment.
Longer rest
period during
admission for
maximum rest
and fasterhealing.
COGNITIVE-
PERCEPTUAL
Experiencing pain on
the Right upper
abdominal quadrant
radiating to the right
scapular area with a
pain scale of 6/10
Experienced
post operative
pain on the
same quadrant
with a pain
scale of 8/10.
Normal Normal
-
7/31/2019 CHOLELITHIASIS [Autosaved]
12/36
SELF-
PERCEPTION
She is now a well
contented mother
having 6 children,
all have their
college degrees,having own
families except
the last child.
Does not
consider herself
as a burden to
her husband and
children.
Patient sees herself
positively.
Normal
ROLE
RELATIONSHIP
Lives with
husband, daughter
and grandchild.
Defines herself as
a very good
mother.
Have a well-
established family
relationship.
She stated that
this confinement
cannot affect her
role as a mother.
Normal Normal
-
7/31/2019 CHOLELITHIASIS [Autosaved]
13/36
SEXUALITY Before she turned
menopause, she
and her husband
were so active in
sex.
Does self-breast
examination
Menopauses 11 yrs
ago.
Still does self
breast examination.
normal
COPING
STRESS
Asks for massage
from her children
when felt stress.
Expresses problems
to family and friends. praying everyday
Praying
everyday
Having some
conversations
with copatients.
Normal
VALUE BELIEF she is a Roman
Catholic
Believes that every
person should have a
strong faith with the
Lord.
Believes in the loving
care of Mother Mary,
Sto. Nino.
Usually goes to
church every
Sundays
Prays Holy Rosary
Felt stronger
faith to God and
became closer
to him.
Wears rosary on
her neck.
Normal
-
7/31/2019 CHOLELITHIASIS [Autosaved]
14/36
PHYSICAL
ASSESMENT
-
7/31/2019 CHOLELITHIASIS [Autosaved]
15/36
Body part Method ofassessment
Actual findings interpretation
Skin Inspection Dry skin Skin may be drybecause of
insufficient fluid
intake
Lips Inspection Dry lips lips may be drybecause of
insufficient fluid
intake
Neck Inspection Presence of scar on
right jaw
Scar from infected
boilAbdomen Inspection
palpation
With right upperdressing
(+) tenderness onincision area
Gallbladder isremoved through anabdominal incision(usually at the right
subcostal)
-
7/31/2019 CHOLELITHIASIS [Autosaved]
16/36
ANATOMY &
PHYSIOLOGY
-
7/31/2019 CHOLELITHIASIS [Autosaved]
17/36
-
7/31/2019 CHOLELITHIASIS [Autosaved]
18/36
-
7/31/2019 CHOLELITHIASIS [Autosaved]
19/36
PATHOPHYSIOLOGY
-
7/31/2019 CHOLELITHIASIS [Autosaved]
20/36
Predisposing
-female
-61 y/o
Precipitating
factors
-obesity
-high fatty and salty
diet
Fat / Cholesterol
Resulting bile
supersaturated with
cholesterol.
Form cholesterol stone.
-fever
-RUQ pain
-Murphys sing
-Biliary colic
-N & VCholelithiasis
-
7/31/2019 CHOLELITHIASIS [Autosaved]
21/36
Obstruction of the cystic
duct
Duodenum secretes
cholecystokinin.
Cholecystolithiasis
Gallbladder becomes
distended and
inflamed
-RUQ pain that may
radiate.
-Fever
-N & V
Bile Obstruction, Bile
Stasis
Gallstones obstruct
cystic duct
-Biliary colic
-
7/31/2019 CHOLELITHIASIS [Autosaved]
22/36
LABORATORY
RESULTS
-
7/31/2019 CHOLELITHIASIS [Autosaved]
23/36
ULTRASOUND REPORTThe gallbladder measures 5.8 X 2.6 cm which is within normal.
There are multiple intraluminal hyperechic foci, largest measuring 1.3 cmwith posterior acoustic shadowing. The wall is smooth and not thickened.
IMPRESSION:CHOLECYSTOLITHIASIS
-
7/31/2019 CHOLELITHIASIS [Autosaved]
24/36
TEST RESULT INTERPRETATION HBA1C 6.0 % Within normal range
BUN 6.24 mmol/L Within normal range
CREATININE 87.2 umol/L Within normal range
SADIUM (Na) 142.5 mmol/L Within normal range
POTASSIUM (K) 3.36 mmol/l HYPOKALEMIA
BLOOD CHEMISTRY
-
7/31/2019 CHOLELITHIASIS [Autosaved]
25/36
NCP
-
7/31/2019 CHOLELITHIASIS [Autosaved]
26/36
ASSESMENT
DIAGNOSIS PLANNING NURSINGINTERVENTIONS
RATIONALE EVALUATION
Subjective:
masakit pa
din yung tahiko, as
verbalizedby
the patient.
Pain scale:
8/10
Objective:
Protectivebehavior
Facial
grimace
irritability
Acute pain
related to
interruption inskin and
tissue layers
with
mechanical
closure.
After 30
minutes of
nursingintervention
the patient
will report
pain is
lessened.
Monitored vital
signs.
Assisted in
different position
like sitting and
side lying
position.
Encouraged
patient to use
relaxation
exercise.
-deep breathing
exercise
Encouragedadequate periods
of rest.
It serves as a
baseline data
to check ifthere are any
deviations from
her vital signs.
It reduces
muscle tension
and fatigue.
Deep breathing
exercise contribute to
relief of pain.
To prevent fatigue.
After 30 minutes of nursing
interventions the patient
reported that the pain waslessened and the pain scale
became 5/10.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
27/36
ASSESMENT DIAGNOSIS PLANNING NURSINGINTERVENTIONS
RATIONALE EVALUATION
Subjective:
Minsan
kumakati yung
paligid ng tahiko, as
verbalized
by the patient.
Objective:
Surgical wound
on the right
upper quadrant.With RUQ
abdominal
dressing
Impaired skin /
tissue integrity
related to
surgery.
After 3 days of
nursing
interventions
the patient willdisplay timely
healing of
wounds without
complications.
inspected skin on
a daily basis,
describing lesions
and changesobserved.
Kept the area
clean and dry,
carefully dress
wound.
Used appropriatebarrier dressings
and wound
coverings.
Instructed in
aseptic/ clean
techniques for
dressing changes
and proper disposalof soiled dressings.
To monitor
progress of
wound healing.
Assist bodys
natural process
of repair.
To protect thewound.
To prevent the
spread of
infectious
agents.
After 3 days of
nursing
interventions the
patient displayedhealing of
wounds without
any
complications.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
28/36
Provided
optimum
nutrition and
encourage to
increase protein
intake.
Encouraged
early
ambulation.
To provide a
positive nitrogen
balance to aid in
healing and to
maintain general
good health.
Promotes
circulation and
reduces risk
associated with
immobility.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
29/36
ASSESMENT DIAGNOSIS PLANNING NURSINGINTERVENTION
S
RATIONALE EVALUATION
Subjective:
Ang sakit ng ulo
ko at ang sama
ng pakiramdam
ko, as
verbalized by the
patient.
Objectives:
T- 38.1C
P- 124
R- 28
Warm to touch
Flushed skin
Hyperthermia
related to
dehydration.
After 30 minutes
of nursing
intervention thepatients
temperature will
decreased and
be able to reach
the normal
range.
Monitored vital
signs.
Performed
tepid sponge
bath.
Promotedventilation of skin
by wearing loose
clothes.
Maintained bed
rest.
Administered
replacement
fluids and
electrolytes as
ordered.
To monitor if
theres
progress.
To promote
cooling of the
body surface.
To facilitate
heat lost.
To reduce
metabolic
demands/
oxygen
consumption.
To support
circulating
volume and
tissue perfusion.
After 30 minutes
of nursing
interventions thetemperature
decreased from
38.1C to 37.6C.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
30/36
DRUGS STUDY
-
7/31/2019 CHOLELITHIASIS [Autosaved]
31/36
Drug Name Classification Action Indication Contraindicati
on
Side effects Nursing
Considerations
Generic Name:
Potassium
Chloride
Brand Name:
Kalium Durule
Electrolytic and
water balance
agent;
replacement
solution.
Essential for
maintenance of
intracellular
isotonicity,
transmission of
nerve impulses.
Plays prominent
role in both
formation andcorrection of
imbalances in
acid- base
metabolism.
To prevent and
treat potassium
deficit
secondary to
diuretic or
corticosteroid
therapy. Also
indicate when
potassium isdepleted by
severe vomiting,
diarrhea;
intestinal
drainage,
fistulas or
malarbsorption;
prolonged
dieresis,
diabetic
acidosis.
Severe renal
impairment;
severe
hemolytic
reaction;
untreated
Adisons
disease; crush
syndrome; earlypost operative
oliguria.
GI: nausea,
vomiting,
diarrhea,
abdominal
distension.
Body as a
whole:
Pain, mental
confusion.Urogenital:
oliguria, anuria.
CV:
hypotension,
bradycardia.
Monitor I & O
ratio and pattern
in patients
receiving the
parenteral drug.
Lab test:
frequent serum
electrolytes are
warranted.Monitor for and
report signs of
GI ulceration (
esophageal of
epigastric pain
or
hematemesis.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
32/36
Drug Name Classification Action Indication Contraindicati
on
Side effects Nursing
Consideration
s
Generic
Name:
Celecoxib
Brand Name:
CELEBREX
Therapeutic:
Anti-
rheumatics,
NSAIDS.
PhysiologicMechanism
Decreasedpain and
inflammationcaused byarthritis
PharmacologicMechanism
Prevention
of Inhibits the
enzyme COX-2.
This enzyme is
required for the
synthesis ofprostaglandins.
Has analgesic,
anti-
inflammatory,
and antipyreticproperties.
Relief of signs
and symptoms
of osteoarthritis. Relief of signs
and symptomsof rheumatoid
arthritis inadults.
Hypersensitivit
y to
cephalosporin
s. Serious
hypersensitivity
to penicillin.
CNS:
Seizures (high
doses) GI:
Pseudomembranous
colitis, diarrhea,
nausea,
vomiting,cramps
GU:
Interstitialnephritis
DERM:
Rashes, urticaria
HEMAT:
Blood
dyscrasias,
hemolyticanemia
Assess
patients range
of motion,degree of
swelling, andpain in affected
joints before and
periodically
throughout
therapy. May be
administered
without regard to
meals. Instruct
patient to take
celecoxib
exactly as
directed. Do not
take more than
prescribed
dose.Increasing
doses does not
appear toincreaseeffectiveness.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
33/36
Drug Name Classification Action Indication Contraindication Side effects Nursing
Consideration
s
Generic
Name:
Metformin
Hydrochloride
Brand Name:
Fortamet,
Apo-Metformin
(CAN)
Antidiabetic Exact
mechanism is
not understood;possibly
increases
peripheral
utilization of
glucose,
decreases
hepatic glucose
production, and
alters intestinal
absorption of
glucose.
Adjunct to
diet to lower
bloodglucose with
type 2
diabetes
mellitus with
patients 10 yr
and older.
Contraindicated to
allergy with
metformin; heartfailure; diabetes
complicated with
fever; sever
trauma; severe
infections
Use cautiously with
elderly
Endocrine:
hypoglycaemia
GI: anorexia,nausea and
vomiting,
heartburn,
diarrhea,
flatulence
Do not
discontinue
meds withoutconsulting
health care
provider
Monitor blood
for blood
glucose as
prescribed
Swallow
extended
tablets do not
crush or chew
Avoid usingalcohol while
taking this drug
Report
hypoglycaemic
and
hypoglycaemic
reactions
-
7/31/2019 CHOLELITHIASIS [Autosaved]
34/36
Drug Name Classification Action Indication Contraindicat
ion
Side effects Nursing
Consideratio
ns
Generic
Name:
Omeprazole
Brand Name:
Prilosec
Proton Pump
Inhibitor
Antisecretory
Drug
Gastric acid
pump inhibitor.
Suppresses
gastric acid
secretion by
specific
inhibition of
the hydrogen-
potassium
ATPase
enzyme
system at the
secretory
surface of the
gastric parietal
cells; blocks
the final stepof acid
production.
Short term
treatment of
active
duodenal
ulcer.
Treatment of
hearturn or
symptoms of
GERD.
Short term
treatment of
active benign
gastric ulcer.
Use cautiously
with
pregnancy,
lactation.
Contraindicate
d with
hypersensitivit
y to
omeprazole or
its
components.
GI: diarrhea,
abdominal
pain, nausea
and vomiting,
constipation,dr
y mouth
Respiratory:
URI
symptoms,
cough,
epistaxis
Other:
Back pain
fever
Administer
befor meals.
Do not crush
or chew
capsules
(swallow
capsule whole)
Have regular
follow up
check ups
Report severe
headaches,
chills and
severediarrhea.
-
7/31/2019 CHOLELITHIASIS [Autosaved]
35/36
-
7/31/2019 CHOLELITHIASIS [Autosaved]
36/36
Medications Omeprazole Metformin
Celebrex
Kalium Durule
Exercise Begin light exercise such as walking.
Deep breathing and coughing exercises.
Treatment Take medications as ordered. Finish medication course.
Health Teaching
Taught proper wound care. If experiencing pain and to ease discomfort sit in an upright position, walking and use of a
heating pad can ease the pain and discomfort. Take analgesics as prescribed. Do not self-medicate.
Out Patient Follow up Attend follow up checkups after one week.
Call your surgeon if you experience any signs and symptoms of infection.
Diet Low Salt Low Fat Diet.
Eat foods that are rich in vitamins and minerals.
Avoid fatty and salty foods.
Spiritual counselling Tell client to verbalize her feelings.
Talk to the relati es to be s pporti e in the clients acti ities for better and faster reco er